- Email: [email protected]
Using clinical notes provided on request forms to assess the risk associated with isolated ureamia
Pathology (2011) 43(S1), pp. S55–S59
DS Nelson Trainee Prize Presentation
DETECTION OF SEPSIS IN NEONATE USING NEUTROPHIL VCS PARAMETERS ON BECKMAN COULTER LH750 HAEMATOLOGY ANALYSER (METHOD INTRODUCTION AND OPTIMISATION IN HAEMATOLOGY LABORATORY AT ROYAL NORTH SHORE HOSPITAL) L. Al-Zadjali, L. Connelly Haematology Department, PaLMs, Royal North Shore Hospital, Sydney, NSW, Australia Identifying neonates at high risk of serious bacterial illness and who therefore require empiric antimicrobial therapy is a challenging problem facing paediatricians in their practice. The blood tests that are traditionally used to detect sepsis in infants besides the cultures include white cell count, neutrophils count and inflammatory markers [C-reactive protein (CRP)]. Despite their common use, observational studies report that these markers have poor sensitivity and specificity for identifying bacteraemia. Quantitative determination of neutrophil VCS parameters by the Beckman Coulter Automated haematology analyser is a new marker and has been shown to be a reliable indicator for acute bacterial infection in several studies. We retrospectively analysed a large dataset of 200 neonates (less than 3 months of age) and their VCS positional parameters MNV (mean neutrophil volume) and NDW (neutrophil distribution width) with the usual laboratory markers to detect infection that includes CRP, manual band count and absolute neutrophils count (ANC). The patients were divided into three categories, those who demonstrated evidence of bacterial infection with positive culture, raised inflammatory markers (ANC, CRP), or with no evidence of infection. In the next 3 months, the data will be analysed to determine sensitivity and specificity and the results will be presented. FEMALE BREAST CANCER IN THE AUSTRALIAN CAPITAL TERRITORY (ACT): A REVIEW OF NEW RESEARCH Claire Behm1,2, Yanping Zhang3, Jane E. Dahlstrom1, Paul S. Craft4, John M. Buckingham5, Angela Rezo4, Robin Stuart-Harris4, Carolyn Cho6 1 ACT Pathology, The Canberra Hospital, Canberra, 2ACT Cancer Registry, ACT Health, Canberra, 3ACT Breast Cancer Treatment Group, ACT Health, Canberra, 4The Canberra Hospital and Australian National University Medical School, Canberra, 5 Calvary Hospital and Australian National University Medical School, Canberra, and 6Lidia Perin Medical Centre, Canberra, ACT, Australia Aim: Review new research to understand better the reported higher rates of breast cancer in the ACT, Australia. Methods: Results of two studies published in 2010 were reviewed.1,2 Rates of breast cancer and risk factors were compared with national figures.
Print ISSN 0031-3025/Online ISSN 1465-3931 DOI: 10.1097/01.PAT.0000394564.28625.f8
#
Results: ACT females had a higher rate of breast cancer, with an age-standardised incidence of 129.6 cases per 100 000 women for 2002–2006, compared with the national average of 113 per 100 000. However, for most years, this higher incidence was not statistically significant. Participation in BreastScreen was similar to the national rate. Breast cancers detected by screening were likely to be smaller, have fewer positive lymph nodes and be treated by breast-conserving surgery. Breast cancer survival improved in the ACT (5-year survival 87% in 1995–1999; 92% in 2000 –2004). Differences in risk factors related to socioeconomic status, fertility, maternal age and alcohol intake could place ACT women at higher risk of breast cancer. Discussion: A higher incidence of breast cancer in the ACT cannot be attributed to a different rate of participation in BreastScreen. ACT females appear to have a different risk factor profile for breast cancer, which could account for the higher incidence. The declining mortality from breast cancer reflects the efficacy of radiological screening, along with adherence to nationally recommended breast cancer treatment guidelines in the ACT. References 1. ACT Cancer Registry, ACT Health. Review of Breast Cancer in ACT Women. Canberra: ACT Government, 2010. 2. Australian Capital Territory and South East New South Wales Breast Cancer Treatment Group (2009). Quality Assurance Project Ten-year Report. Canberra, ACT Health, 2010.
USING CLINICAL NOTES PROVIDED ON REQUEST FORMS TO ASSESS THE RISK ASSOCIATED WITH ISOLATED UREAMIA M. Botros, Z. X. Lu, K. A. Sikaris Melbourne Pathology, Collingwood, Vic, Australia Aims: Clinicians often give clinical information in the ‘notes’ field of the request form which can be helpful. We aimed to determine if these notes could be used to determine the clinical risks associated with uraemia. Method: We reviewed 951 759 requests for U&E. 317,771 requests had no clinical notes and served as a control group. 608 had notes associated with upper GI bleeding ‘UGB’ (H&M, GI bleeding); 1391 with lower GI bleeding ‘LGB’ (PR bleed, colon carcinoma); 3753 with cardiac failure ‘CCF’. Of all U&Es, 22.5% had elevated urea (>8 mmol/L), of which 29.5% had acceptable renal function (eGFR 60 mL/min/1.73 m2). Results: Elevated urea was more commonly found with clinical notes of UGB (1.9-fold risk) or CCF (2.8-fold risk), but not with LGB (0.9-fold risk). The relative likelihood was highest for a urea >12 mmol/L for both UGB (2.8-fold risk) and CCF (3.8-fold risk). Urea >12 mmol/L with acceptable renal function had the highest association for the clinical notes of UGB (9.9-fold risk) and CCF (6.8-fold risk). Discussion: Request form clinical notes are associated with urea abnormalities. This approach may provide useful information
2011 Royal College of Pathologists of Australasia
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
S56
Pathology (2011), 43(S1)
PATHOLOGY 2011 ABSTRACT SUPPLEMENT
when trying to define risk levels such as those for critical result phoning. OUTCOMES IN PRIMARY IMMUNE THROMBOCYTOPENIA (ITP): A RETROSPECTIVE AUDIT ON A SINGLE TERTIARY REFERRAL CENTRE Philip Choi1, Beng Hock Chong1,2 1 Department of Haematology, St George Hospital, Kogarah and 2 Department of Medicine, St George Clinical School, University of NSW, NSW, Australia Aims: To review the presentation and outcome of primary immune thrombocytopenia (ITP) using recent international working group guidelines.1 Methods: 422 possible ITP cases (1/1/2005–1/6/2010) were examined at St George Hospital: medical records, laboratory databases. Results: 67 primary ITP (54 new diagnoses, 13 relapsed): median age 57.8 years, platelet count 34 109/L, females 58%. 48% initial platelet count <30 109/L. 24 month platelet counts: <30 109/L in 9%, 30 109/L in 91% and 100 109/L in 35%. 6 month CR (complete response: platelet count 100 109/L, no bleeding) 25%, and R (response: platelet count 30 109/L, double baseline, no bleeding) 36%. 25 episodes grade III/IV bleeding, 19/67 patients. 54 newly diagnosed primary ITP: 16 treatment free from presentation, median follow-up 13.7 months. 23 required steroids, median duration 53 days. Median time to second-line therapies 49 days. 11 of 17 required second-line within 3 months of presentation. 24 intial platelet count <30 109/L required more treatments (2.6 0.7 versus 0.4 0.4, p ¼ 0.05). Discussion: Patients not requiring treatment at presentation usually remain treatment free. Conversely, most patients requiring additional therapies begin second-line within 3 months of presentation. Reference 1. Rodeghiero F, Stasis R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood 2009; 113: 2386-93.
VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) BLOODSTREAM INFECTIONS (BSI): A CASECONTROLLED ANALYSIS TO ASSESS IMPLICATIONS ON MORTALITY IN HAEMATOLOGY PATIENTS AT A SINGLE TERTIARY REFERRAL CENTRE Philip Young-Ill Choi1, Carrie van der Weyden1, Belinda Straube2, Christine Cook2, Sundra Ramanathan1, Peter Taylor3 1 Department of Haematology, 2Infection Control, and 3Department of Microbiology, SEALS Central, St George Hospital, Kogarah, NSW, Australia Aims: To describe vancomycin resistant enterococcus (VRE) patient characteristics and compare mortality rates to case-matched controls. Methods: Admissions and microbiology from haematologyoncology ward (1/6/2009–1/6/2010) were reviewed. Case-controlled analysis of VRE impact on mortality was undertaken. Results: VRE isolated in 29 [11 bloodstream infections (BSI)]. Mean length of stay (LOS) was significantly longer in VRE than overall haematology (19.2 4.8 versus 10.8 1.4, p ¼ 0.01).
Acute myeloid leukaemia (AML) / acute lymphoblastic leukaemia (ALL) patients accounted for 7 VRE (4 BSI). 33 VRE isolates in 29 separate patients: 16 swabs (mostly rectal), 11 BSI, 5 urine. 16/29 VRE patients died, median time-to-death from detection 30 days (0–236). No significant increase in mortality with VRE BSI compared to other modes: 10/16 (63%) swab, 5/11 (45%) BSI and 4/5 (80%) urine. 8/15 deaths due to progressive disease, 3/15 deaths due to overwhelming sepsis. Case-controlled analysis performed: age, case and stage of disease matched analysis comparing 14 VRE and 14 non-VRE. Median follow-up 272 and 364 days, respectively. Mortality rate 50% versus 29%. Majority of deaths due to progressive disease. Discussion: VRE detection by screening and BSI are increasingly observed at our hospital. Risk factors from our analysis are LOS >20 days and AML/ALL. VRE detection is associated with increased frequency of death but progressive disease remains the most common cause of death. VRE BSI does not appear to confer a worse prognosis. OVERREPORTING OF VITAMIN D LEVELS BY THE ROCHE ELECSYS VITAMIN D3 (25OH) METHOD A. B. Connell1, H-G. Schneider1,2 Clinical Biochemistry Unit, Alfred Pathology Service, Melbourne and 2Monash University, Melbourne, Vic, Australia
1
Vitamin D deficiency is common, and is associated with increased risk of osteoporosis and, increasingly, is shown to have association with many other illnesses. There are many ways to measure vitamin D, but all can suffer from precision and bias. Recently, Roche removed its Elecsys Vitamin D3 (25OH) electrochemiluminescence immunoassay (ECLIA) from the market, citing deteriorating traceability to the reference method. We investigated the performance of two formulations of the Roche immunoassay against the reference method (liquid chromatography tandem mass spectrometry). A set of samples was assayed for vitamin D using the polyclonal formulation of the Elecsys electrochemiluminescence immunoassay, and the monoclonal immunoassay. A subset of samples was assayed for vitamin D3 using LCMSMS. The correlation between the monoclonal formulation of ECLIA and LCMSMS was: ECLIA (monoclonal) ¼ 0.31 LCMSMS þ 23, r2 ¼ 0.27. The correlation between the monoclonal and polyclonal formulations of the ECLIA was: ECLIA (monoclonal) ¼ 0.93 ECLIA (polyclonal) – 3, r2 ¼ 0.60. At the time of its removal from market, the Roche Elecsys vitamin D3 (25OH) electrochemiluminescence immunoassay had unacceptable performance, markedly under-reporting vitamin D levels. The bias likely preceded the introduction of the monoclonal formulation of the immunoassay. LOW EXTENT BONE MARROW INVOLVEMENT IN NEWLY DIAGNOSED FOLLICULAR LYMPHOMA: DIAGNOSIS AND CLINICAL CORRELATES Jane Gordon1, Ritam Prasad1, Arno Enno1, Antonino Bonaventura2, Anoop Enjeti1, Philip Rowlings1 1 Department of Haematology, Calvary Mater Newcastle and 2 Department of Medical Oncology, Calvary Mater Newcastle, NSW, Australia
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
DS Nelson Trainee Prize Presentation
DETECTION OF SEPSIS IN NEONATE USING NEUTROPHIL VCS PARAMETERS ON BECKMAN COULTER LH750 HAEMATOLOGY ANALYSER (METHOD INTRODUCTION AND OPTIMISATION IN HAEMATOLOGY LABORATORY AT ROYAL NORTH SHORE HOSPITAL) L. Al-Zadjali, L. Connelly Haematology Department, PaLMs, Royal North Shore Hospital, Sydney, NSW, Australia Identifying neonates at high risk of serious bacterial illness and who therefore require empiric antimicrobial therapy is a challenging problem facing paediatricians in their practice. The blood tests that are traditionally used to detect sepsis in infants besides the cultures include white cell count, neutrophils count and inflammatory markers [C-reactive protein (CRP)]. Despite their common use, observational studies report that these markers have poor sensitivity and specificity for identifying bacteraemia. Quantitative determination of neutrophil VCS parameters by the Beckman Coulter Automated haematology analyser is a new marker and has been shown to be a reliable indicator for acute bacterial infection in several studies. We retrospectively analysed a large dataset of 200 neonates (less than 3 months of age) and their VCS positional parameters MNV (mean neutrophil volume) and NDW (neutrophil distribution width) with the usual laboratory markers to detect infection that includes CRP, manual band count and absolute neutrophils count (ANC). The patients were divided into three categories, those who demonstrated evidence of bacterial infection with positive culture, raised inflammatory markers (ANC, CRP), or with no evidence of infection. In the next 3 months, the data will be analysed to determine sensitivity and specificity and the results will be presented. FEMALE BREAST CANCER IN THE AUSTRALIAN CAPITAL TERRITORY (ACT): A REVIEW OF NEW RESEARCH Claire Behm1,2, Yanping Zhang3, Jane E. Dahlstrom1, Paul S. Craft4, John M. Buckingham5, Angela Rezo4, Robin Stuart-Harris4, Carolyn Cho6 1 ACT Pathology, The Canberra Hospital, Canberra, 2ACT Cancer Registry, ACT Health, Canberra, 3ACT Breast Cancer Treatment Group, ACT Health, Canberra, 4The Canberra Hospital and Australian National University Medical School, Canberra, 5 Calvary Hospital and Australian National University Medical School, Canberra, and 6Lidia Perin Medical Centre, Canberra, ACT, Australia Aim: Review new research to understand better the reported higher rates of breast cancer in the ACT, Australia. Methods: Results of two studies published in 2010 were reviewed.1,2 Rates of breast cancer and risk factors were compared with national figures.
Print ISSN 0031-3025/Online ISSN 1465-3931 DOI: 10.1097/01.PAT.0000394564.28625.f8
#
Results: ACT females had a higher rate of breast cancer, with an age-standardised incidence of 129.6 cases per 100 000 women for 2002–2006, compared with the national average of 113 per 100 000. However, for most years, this higher incidence was not statistically significant. Participation in BreastScreen was similar to the national rate. Breast cancers detected by screening were likely to be smaller, have fewer positive lymph nodes and be treated by breast-conserving surgery. Breast cancer survival improved in the ACT (5-year survival 87% in 1995–1999; 92% in 2000 –2004). Differences in risk factors related to socioeconomic status, fertility, maternal age and alcohol intake could place ACT women at higher risk of breast cancer. Discussion: A higher incidence of breast cancer in the ACT cannot be attributed to a different rate of participation in BreastScreen. ACT females appear to have a different risk factor profile for breast cancer, which could account for the higher incidence. The declining mortality from breast cancer reflects the efficacy of radiological screening, along with adherence to nationally recommended breast cancer treatment guidelines in the ACT. References 1. ACT Cancer Registry, ACT Health. Review of Breast Cancer in ACT Women. Canberra: ACT Government, 2010. 2. Australian Capital Territory and South East New South Wales Breast Cancer Treatment Group (2009). Quality Assurance Project Ten-year Report. Canberra, ACT Health, 2010.
USING CLINICAL NOTES PROVIDED ON REQUEST FORMS TO ASSESS THE RISK ASSOCIATED WITH ISOLATED UREAMIA M. Botros, Z. X. Lu, K. A. Sikaris Melbourne Pathology, Collingwood, Vic, Australia Aims: Clinicians often give clinical information in the ‘notes’ field of the request form which can be helpful. We aimed to determine if these notes could be used to determine the clinical risks associated with uraemia. Method: We reviewed 951 759 requests for U&E. 317,771 requests had no clinical notes and served as a control group. 608 had notes associated with upper GI bleeding ‘UGB’ (H&M, GI bleeding); 1391 with lower GI bleeding ‘LGB’ (PR bleed, colon carcinoma); 3753 with cardiac failure ‘CCF’. Of all U&Es, 22.5% had elevated urea (>8 mmol/L), of which 29.5% had acceptable renal function (eGFR 60 mL/min/1.73 m2). Results: Elevated urea was more commonly found with clinical notes of UGB (1.9-fold risk) or CCF (2.8-fold risk), but not with LGB (0.9-fold risk). The relative likelihood was highest for a urea >12 mmol/L for both UGB (2.8-fold risk) and CCF (3.8-fold risk). Urea >12 mmol/L with acceptable renal function had the highest association for the clinical notes of UGB (9.9-fold risk) and CCF (6.8-fold risk). Discussion: Request form clinical notes are associated with urea abnormalities. This approach may provide useful information
2011 Royal College of Pathologists of Australasia
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
S56
Pathology (2011), 43(S1)
PATHOLOGY 2011 ABSTRACT SUPPLEMENT
when trying to define risk levels such as those for critical result phoning. OUTCOMES IN PRIMARY IMMUNE THROMBOCYTOPENIA (ITP): A RETROSPECTIVE AUDIT ON A SINGLE TERTIARY REFERRAL CENTRE Philip Choi1, Beng Hock Chong1,2 1 Department of Haematology, St George Hospital, Kogarah and 2 Department of Medicine, St George Clinical School, University of NSW, NSW, Australia Aims: To review the presentation and outcome of primary immune thrombocytopenia (ITP) using recent international working group guidelines.1 Methods: 422 possible ITP cases (1/1/2005–1/6/2010) were examined at St George Hospital: medical records, laboratory databases. Results: 67 primary ITP (54 new diagnoses, 13 relapsed): median age 57.8 years, platelet count 34 109/L, females 58%. 48% initial platelet count <30 109/L. 24 month platelet counts: <30 109/L in 9%, 30 109/L in 91% and 100 109/L in 35%. 6 month CR (complete response: platelet count 100 109/L, no bleeding) 25%, and R (response: platelet count 30 109/L, double baseline, no bleeding) 36%. 25 episodes grade III/IV bleeding, 19/67 patients. 54 newly diagnosed primary ITP: 16 treatment free from presentation, median follow-up 13.7 months. 23 required steroids, median duration 53 days. Median time to second-line therapies 49 days. 11 of 17 required second-line within 3 months of presentation. 24 intial platelet count <30 109/L required more treatments (2.6 0.7 versus 0.4 0.4, p ¼ 0.05). Discussion: Patients not requiring treatment at presentation usually remain treatment free. Conversely, most patients requiring additional therapies begin second-line within 3 months of presentation. Reference 1. Rodeghiero F, Stasis R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood 2009; 113: 2386-93.
VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) BLOODSTREAM INFECTIONS (BSI): A CASECONTROLLED ANALYSIS TO ASSESS IMPLICATIONS ON MORTALITY IN HAEMATOLOGY PATIENTS AT A SINGLE TERTIARY REFERRAL CENTRE Philip Young-Ill Choi1, Carrie van der Weyden1, Belinda Straube2, Christine Cook2, Sundra Ramanathan1, Peter Taylor3 1 Department of Haematology, 2Infection Control, and 3Department of Microbiology, SEALS Central, St George Hospital, Kogarah, NSW, Australia Aims: To describe vancomycin resistant enterococcus (VRE) patient characteristics and compare mortality rates to case-matched controls. Methods: Admissions and microbiology from haematologyoncology ward (1/6/2009–1/6/2010) were reviewed. Case-controlled analysis of VRE impact on mortality was undertaken. Results: VRE isolated in 29 [11 bloodstream infections (BSI)]. Mean length of stay (LOS) was significantly longer in VRE than overall haematology (19.2 4.8 versus 10.8 1.4, p ¼ 0.01).
Acute myeloid leukaemia (AML) / acute lymphoblastic leukaemia (ALL) patients accounted for 7 VRE (4 BSI). 33 VRE isolates in 29 separate patients: 16 swabs (mostly rectal), 11 BSI, 5 urine. 16/29 VRE patients died, median time-to-death from detection 30 days (0–236). No significant increase in mortality with VRE BSI compared to other modes: 10/16 (63%) swab, 5/11 (45%) BSI and 4/5 (80%) urine. 8/15 deaths due to progressive disease, 3/15 deaths due to overwhelming sepsis. Case-controlled analysis performed: age, case and stage of disease matched analysis comparing 14 VRE and 14 non-VRE. Median follow-up 272 and 364 days, respectively. Mortality rate 50% versus 29%. Majority of deaths due to progressive disease. Discussion: VRE detection by screening and BSI are increasingly observed at our hospital. Risk factors from our analysis are LOS >20 days and AML/ALL. VRE detection is associated with increased frequency of death but progressive disease remains the most common cause of death. VRE BSI does not appear to confer a worse prognosis. OVERREPORTING OF VITAMIN D LEVELS BY THE ROCHE ELECSYS VITAMIN D3 (25OH) METHOD A. B. Connell1, H-G. Schneider1,2 Clinical Biochemistry Unit, Alfred Pathology Service, Melbourne and 2Monash University, Melbourne, Vic, Australia
1
Vitamin D deficiency is common, and is associated with increased risk of osteoporosis and, increasingly, is shown to have association with many other illnesses. There are many ways to measure vitamin D, but all can suffer from precision and bias. Recently, Roche removed its Elecsys Vitamin D3 (25OH) electrochemiluminescence immunoassay (ECLIA) from the market, citing deteriorating traceability to the reference method. We investigated the performance of two formulations of the Roche immunoassay against the reference method (liquid chromatography tandem mass spectrometry). A set of samples was assayed for vitamin D using the polyclonal formulation of the Elecsys electrochemiluminescence immunoassay, and the monoclonal immunoassay. A subset of samples was assayed for vitamin D3 using LCMSMS. The correlation between the monoclonal formulation of ECLIA and LCMSMS was: ECLIA (monoclonal) ¼ 0.31 LCMSMS þ 23, r2 ¼ 0.27. The correlation between the monoclonal and polyclonal formulations of the ECLIA was: ECLIA (monoclonal) ¼ 0.93 ECLIA (polyclonal) – 3, r2 ¼ 0.60. At the time of its removal from market, the Roche Elecsys vitamin D3 (25OH) electrochemiluminescence immunoassay had unacceptable performance, markedly under-reporting vitamin D levels. The bias likely preceded the introduction of the monoclonal formulation of the immunoassay. LOW EXTENT BONE MARROW INVOLVEMENT IN NEWLY DIAGNOSED FOLLICULAR LYMPHOMA: DIAGNOSIS AND CLINICAL CORRELATES Jane Gordon1, Ritam Prasad1, Arno Enno1, Antonino Bonaventura2, Anoop Enjeti1, Philip Rowlings1 1 Department of Haematology, Calvary Mater Newcastle and 2 Department of Medical Oncology, Calvary Mater Newcastle, NSW, Australia
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.